Provider Demographics
NPI:1285957308
Name:JOHNSON, REBECCA G (CNM)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 LONE OAK RD STE 245
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7941
Mailing Address - Country:US
Mailing Address - Phone:270-538-5700
Mailing Address - Fax:270-538-5701
Practice Address - Street 1:1532 LONE OAK RD STE 245
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7941
Practice Address - Country:US
Practice Address - Phone:270-538-5700
Practice Address - Fax:270-538-5701
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006383363LW0102X, 363LX0001X, 367A00000X
TNAPN16127367A00000X
KY6383M367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100203570OtherKY MEDICAID
TN1525514Medicaid
TN3380640OtherGROUP MEDICAID
KYK009831OtherKY MEDICARE PTAN
TN3380640OtherGROP MEDICARE
KY7100203570OtherKY MEDICAID